Provider Demographics
NPI:1376519454
Name:SALEM FAMILY CLINIC
Entity Type:Organization
Organization Name:SALEM FAMILY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:N
Authorized Official - Last Name:MOODY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-895-2541
Mailing Address - Street 1:PO BOX 829
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:AR
Mailing Address - Zip Code:72576-0829
Mailing Address - Country:US
Mailing Address - Phone:870-895-2541
Mailing Address - Fax:870-895-2957
Practice Address - Street 1:507 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:AR
Practice Address - Zip Code:72576-9449
Practice Address - Country:US
Practice Address - Phone:870-895-2541
Practice Address - Fax:870-895-2957
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-27
Last Update Date:2010-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARMC0433208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR102260002Medicaid
AR102260002Medicaid